Provider Demographics
NPI:1770719775
Name:ENNIS, SHANNON KAY (AT)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:KAY
Last Name:ENNIS
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5537 BLEAUX AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-0737
Mailing Address - Country:US
Mailing Address - Phone:479-872-5580
Mailing Address - Fax:479-872-5581
Practice Address - Street 1:1300 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-9403
Practice Address - Country:US
Practice Address - Phone:501-208-5911
Practice Address - Fax:501-208-5912
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor